Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Learning Outcomes
1.
Define nutrition, nutrients, energy balance.
2.
Identify factors influencing nutrition.
3.
Identify nutritional variations among adults.
4.
Discuss essential components and purposes of nutritional assessment and nutritional
screening.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Learning Outcomes (cont'd)
5. Identify risk factors for and clinical signs of malnutrition.
6. Describe nursing interventions to promote optimal nutrition.
7. Discuss nursing interventions to treat clients with nutritional
problems.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Learning Outcomes (cont'd)
9. Plan, implement, and evaluate nursing care associated with nursing diagnoses related to
nutritional problems.
10. Demonstrate appropriate documentation and reporting of nutritional therapy
11. Verbalize the steps used for:
a)
Measuring body weight and height
b)
Inserting a nasogastric tube
c)
Removing a nasogastric tube
d)
Administering a tube feeding
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
is the sum of all the
interactions between
an organism and the
food it consumes
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Essential Nutrients
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Energy Balance
•Relationship between energy derived
from food and energy used by body
•energy intake vs. energy output
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Energy Balance
•Body obtains energy in form of calories
from carbohydrates, proteins, & fats
•Body uses energy for voluntary activities
such as walking, talking and for involuntary
activities such as breathing and secreting
enzymes
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Energy Balance
Energy intake: Amount of energy that foods
supply to body is caloric value
Energy output : Metabolism refers to all
biochemical & physiological processes by
which body grows & maintains itself
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Energy Balance
Rate of heat liberated during chemical reaction
is metabolic rate.
•Basal metabolic rate (BMR) is rate at which
body metabolizes food to maintain energy
requirement of a person who is awake & at rest
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
• Development
• Gender
Factors Influencing Nutrition
• Ethnicity and culture
• Beliefs about food
• Personal preferences
• Religious practices
• Lifestyle
• Economics
• Medications and
therapy
• Health
• Alcohol consumption
• Advertising
• Psychological factors
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Development:
•Adolescence rapid period of growth with increased
needs for nutrients.
•Older adults need fewer calories and need some
dietary changes with their increased risk for CHD,
osteoporosis, & hypertension
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Gender:
•Nutrient requirements differ between males & females
(body composition and reproductive functions).
•Larger muscle mass in men means greater needs for
calories and proteins
•Females need more iron than men prior to menopause
•Pregnant and lactating women have ↑ fluid & caloric
needs
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Ethnicity and culture:
Ethnicity determines food preferences
•However, universally accepted guidelines:
Eat a wide variety of foods to supply adequate
nutrients
Eat moderately to maintain body weight
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Beliefs about food
•Beliefs about effects of foods on health can affect food
choices; people acquire their beliefs from television,
magazines, and other media.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Personal preferences:
• People develop likes and dislikes based on associations with foods (foods
prepared by mother or grandmother) and are sometimes carried through
adulthood; likes and dislikes can also be related to familiarity
• Preferences in tastes, smells, flavors, temperatures, colors, shapes, and
sizes of food influence person’s food choices; textures also play great role
in food preferences
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Lifestyle:
Certain lifestyles are linked to food-related behavior
(people who stay at home prepare foods from
scratch; people in a hurry might eat more readymade meals)
Muscular activity affects metabolic rate more than
any other factor
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Economics:
What, how much, and how often a person eats is
affected by socioeconomic status; also affected:
food preparation and food storage facilities
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Medications and therapy:
•Some medications may change appetite, disturb taste perception
or interfere with nutrient absorption or excretion
•Some nutrients can decrease drug absorption; others enhance
absorption
•Older adults are at increased risk for drug-food interactions due to
number of medications they take, decrease in renal or hepatic
functions, and age-related changes
•Chemotherapy may adversely affect eating patterns and nutrition
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Table 47-1 Selected Drug–
Nutrient Interactions
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Table 47-1 Selected Drug–
Nutrient Interactions
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Health:
Factors Influencing Nutrition
•Client’s health status: missing teeth, ill-fitting dentures
& dysphagia can prevent person from getting adequate
nourishment
•Disease processes & surgery of GI tract can affect
digestion, absorption, metabolism and excretion; create
nausea, vomiting, and diarrhea
•Gallstones (affecting flow of bile) will affect lipid
digestion
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Alcohol consumption:
•Alcohol has large number of calories, can lead to
weight gain; excessive alcohol use contributes to
nutritional deficiencies, can depress appetite, toxic
effect on intestinal mucosa leading to decrease in
absorption of nutrients
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Factors Influencing Nutrition
Advertising: influences people’s food choices and eating patterns
to some extent.
• Advertising targets products such as coffee, frozen foods and soft
drinks more than advertising breads, vegetables and fruits
• Australia, Canada, Sweden and England have adopted regulations
prohibiting food advertising on programs targeting young
children
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Psychological
factors.
Factors Influencing Nutrition
•Psychological status may affect eating patterns
•Anorexia and weight loss can indicate severe stress or
depression
•In female adolescents: bulimia (binge eating and
purging); anorexia nervosa (distorted body selfperception, food restriction, inappropriate eating
habits or rituals, obsession with having thin figure,
irrational fear of weight gain)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Variations
•Adolescents
•Increased need for nutrients and calories during
growth spurts (protein, Ca, vitamin D, Fe and B
vitamins)
•Have active lifestyles and irregular eating patterns
•Encourage healthy snacks and limit junk foods
•Common problems: obesity, anorexia nervosa and
bulimia
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Young adults
Nutritional
• Nutritional(cont’d)
habits established earlier
Variations
• Need help in knowing how many servings of each food group is
needed
• Young adult females need adequate Fe intake (iron-rich foods:
organ meats, eggs, fish, poultry, leafy vegetables, and dried
fruits) to prevent Fe deficiency anemia; folic acid supplements
for all women of child-bearing ability (to prevent neural tube
defects in fetus)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional
Variations (cont’d)
•Young
adults (cont.)
•Adequate intake of Ca to maintain bones and decrease chances
of osteoporosis in later life
•Adequate intake of vitamin D, necessary for entry of Ca into
bloodstream; if no sufficient sun exposure, supplements
indicated
•Obesity common in sedentary adults: at risk of hypertension
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Middle-aged
adults
Nutritional
Variations
(cont’d)
• Continue to eat healthy diet, special attention to protein and calcium
intake & limit cholesterol and caloric intake
• 2-3 liters of fluid in daily diet
• Postmenopausal women need to take sufficient Ca and vitamin D to
reduce osteoporosis; antioxidants such as vitamins A, C, and E reduce
risk of heart disease in women
• At risk of obesity, reduce caloric intake and do regular exercise; also
at risk for DM, hypertension, and arthritis
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Variations (cont'd)
Older adults
•Require same basic nutrition as younger adult, but
fewer calories due to lower metabolic rate and
decrease in physical activity
•Some may need more carbohydrates for fiber and
bulk, but most nutrient requirements remain
relatively unchanged
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Older
adults
(cont.) (cont'd)
Nutritional
Variations
•Physical changes as teeth loss and impaired sense of
taste and smell may affect eating habits
•Decreased saliva and gastric juice secretion may also
affect nutrition
•Psychological factors such as depression, loss of
spouse, empty nest may result in poor dietary habits
•Factors such as lack of transportation, poor access to
stores, and inability to prepare food, lowered
income also affect nutritional status
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Lack of necessary or appropriate food
substances; includes both over nutrition
and undernutrition
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Over nutrition: caloric intake in excess of daily energy
requirements, resulting in fat storage leading to
overweight or obesity which predisposes to chronic health
problems. If obesity affects mobility /breathing, it is called
morbid obesity
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Undernutrition: intake of nutrients insufficient to meet
daily energy requirements because of inadequate food
intake or improper digestion & absorption of food
Inadequate nutrition results in weight loss, weakness,
delayed wound healing, altered functional ability,
susceptibility to infection, impaired pulmonary
function, prolonged hospital stay
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Assessing
•Responsibility of nutritional assessment: primary
care provider, dietician and nurse
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Screening and Assessment
(cont’d)
•Nutritional screening
•Nursing history
•Anthropometric measurements
•Biochemical (laboratory) data
•Physical examination
•Dietary data
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Nutritional screening
•comprehensive nutritional assessment is time
consuming and expensive, other types of assessment
done
Nutritional screen: performed by nurses to
identify clients at risk for malnutrition or those who
are undernourished (done through routine nursing
history and physical examination); those with
moderate or high risk for malnutrition, f/u with
comprehensive assessment by dietitian
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Box 47-7 Nutritional Screening Tool
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Screening
Nursing history: obtained in routine admission
nursing history
•age, sex, activity level
•difficulty eating (impaired chewing or swallowing)
•condition of teeth, mouth, dentures
•changes in appetite
•changes in weight
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Screening
Nursing history (cont.)
•physical disabilities that affect purchasing, preparing
and eating
•cultural and religious beliefs
•living arrangements (living alone), economic status
•general health status & medical condition
•medication history
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Anthropometric measurements (anthropometry: scientific
study of the measurements and proportions of the human body)
Anthropometric measurements are noninvasive
techniques that aim to quantify body composition:
Height and weight (nursing skill)
Skin fold measurement (non nursing skill)
Mid-arm circumference (non nursing skill)
Mid-arm muscle area (non nursing skill)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Skin fold measurement
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Mid-arm circumference
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Mid-arm muscle area
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Biochemical (Laboratory) Data
Most common tests:
•Serum proteins
•Urinary tests: urinary urea nitrogen & urinary
creatinine
•Total lymphocyte count
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Serum protein levels give estimate of visceral
protein stores
Tests include: hemoglobin, albumin, and
transferrin, total lymphocyte count
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Low hemoglobin level may be evidence of iron
deficiency anemia
rule out: abnormal blood loss or pathologic process like
GI cancer
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Albumin: accounts for over 50% of total serum protein;
albumin half life of 18-20 days, so albumin concentrations
change slowly; thus, low serum albumin level is indicator of
prolonged protein depletion. However other reasons for
decreased albumin concentration: altered liver function,
hydration status and losses from open wounds and burns
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Serum proteins
• Transferrin binds & carries iron from intestine through the serum. With its shorter
half-life than albumin (8-9 days), transferrin responds more quickly to protein
depletion than albumin
• Transferrin levels below normal are found with protein loss, Fe deficiency anemia,
pregnancy, liver dysfunction
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Serum proteins
•Total lymphocyte count
The total number of lymphocyte white blood cells decreases as protein
depletion occurs
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Urinary urea & urinary creatinine are measures of
protein catabolism & the state of nitrogen balance
•Urea: chief end product of amino acid metabolism, is
detoxified by liver, circulated in blood, and transported to
kidneys for excretion in urine; urea concentrations in
blood & urine directly reflect intake & breakdown of
dietary protein, rate of urea production in liver and rate of
urea removal by kidneys
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Urinary creatinine reflects person’s total muscle mass;
the greater the muscle mass, the greater the excretion
of creatinine; as skeletal muscle atrophies during
malnutrition, creatinine excretion decreases
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Assessment
Clinical data (physical examination)
Assessment focuses on skin, hair, nails, eyes,
and mucosa
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Assessment
Clinical data (physical examination)
•Calculating percentage of weight
loss: (compare current body weight with usual body
weight; any weight loss or gain, duration and if intentional or
unintentional)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Body weight and body mass standards
•Maintaining healthy or ideal body weight
requires balance between expenditure of
energy and intake of nutrients
•When energy requirements of an individual
equate with the daily caloric intake, body
weight remains stable
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Measuring body weight
Electronic scale
Physician Mechanical
Beam Scale
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Body weight and body mass standards
Ideal body weight: optimal weight
recommended for optimal health; consult
standardized tables.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
IBW
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Body weight and body mass standards
•Many health professionals consider body mass index (BMI)
to be more reliable indicator of person's healthy weight
•For people older than 18 years, BMI is indicator of changes in
body fat stores and whether person’s weight is appropriate
for height
•Caution: results must be used with caution in people with
fluid retention, athletes, or older adults
BMI = weight (kg)
(height in meters)²
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
BMI
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
•Percent
body fat (men 6-19%; women 13-31%)
Other Measures
https://www.youtube.com/watch?v=saR8zNPRTio
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Other Measures
•Waist circumference
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Other Measures
•Skinfold testing (skill not required of you)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Other Measures
•Bioelectrical impedance analysis: to estimate body fat, it
determines the electrical impedance, or opposition to the flow
of an electric current through body tissues which can then be
used to estimate total body water (TBW), which can be used to
estimate fat-free body mass and, by difference with body
weight, body fat
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Bioelectrical impedance analysis
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Assessment
•Dietary data (client’s usual eating patterns
and habits, food preferences, allergies, and
intolerances)
24-hr food recall: typical 24-hr food recall when at home
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Assessment
Dietary data (cont.)
food frequency record: checklist that indicates how often general food
groups or specific foods are eaten, could be times/day, or times/week,
times/month, seldom, or never; no indication here of quantities
consumed, only types of foods
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutritional Assessment
• Dietary data (cont.)
food diary: detailed record of measured amounts of all foods
and fluids consumed during specified period, usually 3-7 days
diet history: comprehensive time consuming assessment of
client’s food intake done by nutritionist or dietitian
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
NANDA Nursing Diagnoses
•Related to nutritional problems:
•Imbalanced Nutrition: Less Than Body
Requirements
•Obesity
•Overweight
•Readiness for enhanced nutrition
•Feeding Self-Care Deficit
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Planning
Major goals for clients with or at risk for nutritional
problems include:
•Maintain or restore optimal nutritional status
•Promote healthy nutritional practices
•Prevent complications associated with malnutrition
•Decrease weight
•Regain specified weight
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Implementing
•Hospitalized Client
Provided in collaboration with the primary care provider and the
dietician
•Reinforce information presented by dietician
•Create an atmosphere that encourages eating
•Provide and assist with eating
•Monitor the client’s appetite and food intake
•Administer enteral and parenteral feedings
•Consult with primary care provider and dietician about
nutritional problems
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Implementing
•Assisting with diet: for hospitalized
clients
regular diet 2,000 Kcal menu to
choose from
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Implementing
•Assisting with diet: for hospitalized clients
light diet (postoperative/those not ready for
regular diet): plainly cooked, minimal fat & lots of
fiber.
Diets include: clear liquid, full liquid, soft diet, &
diet as tolerated.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Implementation
Clear liquid diet
• Limited to water, tea, coffee, clear broths,
strained and clear juices, and plain gelatin,
carbonated beverages
• Supplies client with fluid and carbohydrates (in
form of sugar) but not adequate protein, fat,
vitamins, minerals or calories
• It is a short-term diet (24 to 36 hours) provided
to clients after surgeries or in acute stages of
infection, especially of GI tract
• Major objectives of this diet: relieve thirst,
prevent dehydration, and minimize stimulation
of GI tract
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Full liquid diet
•Contains only liquids or foods
that turn into liquid at body
temperature, e.g.: ice cream,
yogurt, custards
•For client with GI disturbances
or who cannot tolerate solid or
semisolid foods.
•Not recommended long-term:
low in Fe, protein, calories;
cholesterol content high due to
cow’s milk
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Soft diet
•Easily chewed & digested, for clients with difficulty
chewing and swallowing,
•Low fiber diet; soft /semisoft diet e.g., pureed diet
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
DietI as tolerated
•Ordered when client’s appetite,
ability to eat and tolerance for
certain foods may change
•Example,
on first postoperative day, clear
liquid diet
if no nausea, active bowel
sounds, client reports passing gas
and feels like eating, advance to
full liquid, light or regular diet
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Box 47-9 Examples of Foods for Clear Liquid, Full
Liquid, and Soft Diets
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Common Terminologies related to Diet
•DAT - Diet as Tolerated
•LSLF - Low Salt Low Fat
•HAD - Hypoallergenic Diet
•NDCF - No Dark-colored Foods
•DM Diet - Diabetic Mellitus Diet/ Diabetic Diet
•SAP - Strict Aspiration Precaution
•OTF - Osteorized Tube Feeding
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Assisting Clients with Meals
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
92
Assisting Clients with Meals
• Clients who frequently need assistance with their meals include:
Older adults who are weakened
Individuals with disabilities such as visual impairment (use clock system to
describe location of food on plate) Box 47-10
Clients who must remain in back-lying position
Clients who cannot use their hands
• Whenever possible, nurse should help clients feed themselves rather
than feed them
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
93
Figure 47-11 For a client who is blind, the nurse can
use the clock system to describe the location of food on
the plate.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Assisting
Clients
with Meals
• Nurses should
try to appear
unhurried and convey that they have ample time
• Ask client in which order he likes to eat the food (if client cannot see, tell client
which food is being given)
• Always allow ample time for the client to chew and swallow the food before
offering more
• Also, provide fluids as requested or, if the client cannot communicate, offer fluids
after every three or four mouthfuls of solid food.
• Make mealtime a pleasant one, choosing topics of conversation that are of
interest to clients who want to talk
• Although normal utensils should be used whenever possible, special utensils may
be needed to assist a client to eat and promote independence
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95
Figure 47-12 Left to right: glass holder, cup with hole
for nose, two-handled cup holder.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Figure 47-13 Dinner plate with guard attached and
lipped plate facilitate scooping; wide-handled spoon
and knife facilitate grip.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Box 47-11 Providing Client Meals
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Nutrition
•When client cannot ingest foods or upper GI tract is
impaired and transport of food to small intestine is
interrupted , alternative feeding methods that
ensure adequate nutrition include enteral (through
GI system) methods
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral access devices
•Achieved through:
1. Nasogastric or nasointestinal tubes
or
2. Gastrostomy or jejunostomy tubes
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
NGT
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
NGT, Gastrostomy, Jejunostomy Tube
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Purposes of Nasogastric Tube Insertion
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Audrey Berman • Shirlee Snyder
103
unable to eat by mouth or swallow a sufficient diet without
Purposes
aspirating food or fluids into the lungs
Nasogastric
Tube Insertion
• To prevent nausea, vomiting, and gastric distention following
surgery. In this case, the tube is attached to a suction source
• To remove stomach contents for laboratory
analysis
https://www.msdmanuals.com/professional/gastrointestinal-disorders/diagnostic-and-therapeutic-gastrointestinalprocedures/gastric-analysis
• To lavage (wash) the stomach in case of poisoning or
overdose of medications
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Nutrition
•Nasogastric tube inserted through one of nostrils,
down nasopharynx and into alimentary tract placed
into stomach.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Indications for nasogastric tube
•Feed clients with adequate gastric emptying and
who require short-term feedings
Not advised for feeding clients without intact gag
and cough reflexes because risk of accidental
placement of tube into the lungs is much higher in
those clients
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106
Inserting a Nasogastric Tube Swallowing closes the
epiglottis.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Nutrition
Nasogastric Tubes
•Feeding tubes come in various sizes.
•Larger tubes may be needed to pass medications
without clogging.
•Smaller, more flexible ones are more comfortable for
the patient.
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108
Inserting a Nasogastric Tube Measuring the
appropriate length to insert a nasogastric tube.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Inserting a Nasogastric Tube Taping a nasogastric
tube to the bridge of the nose.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Nutrition
Nasogastric Tubes
Traditional firm, large-bore
nasogastric tubes
• Levin tube, flexible rubber
or plastic, single-lumen
tube with holes near the
tip
• Salem sump tube, with a
double lumen
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Double-lumen Salem
sump tube with filter on
air vent port and
111
connector on suction
Enteral Nutrition
Nasogastric Tubes
•Softer, more flexible and less irritating
small-bore feeding tubes , smaller than
12 Fr in diameter, are frequently used for
enteral nutrition
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112
Enteral Nutrition
•Nasoenteric (nasointestinal) tube is
longer tube than NGT (at least 40 cm for
an adult), inserted through one nostril
down into upper small intestine.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Figure 47-15 Nasoenteric feeding tubes: A, 12 Fr 36 in.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Copyright ©2012 by Pearson Education, Inc.
All rights reserved.
A
Figure 47-15 (continued) Nasoenteric feeding tubes: B, 8 Fr opaque, 45 in., stylet, weighted tip. Note that both have a Y-port connector to permit irrigation
and medication administration without disconnecting the feeding device.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Copyright ©2012 by Pearson Education, Inc.
All rights reserved.
B
Used for clients at risk for aspiration, such as
those with:
1.Decreased level of consciousness
2.Poor cough or gag reflexes
3.Inability to participate in procedure
4.Restlessness or agitation
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Nutrition
•Gastrostomy and jejunostomy devices used for longterm nutritional support, generally more than 6-8
weeks
•Tubes placed surgically or by laparoscopy through
abdominal wall into stomach (gastrostomy) or
jejunum (jejunostomy)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
gastrostomy (PEG) tube
Enteral Nutrition
• A percutaneous endoscopic gastrostomy (PEG) or percutaneous
endoscopic jejunostomy (PEJ) is created by using an endoscope to
visualize the inside of the stomach, making a puncture through the skin
and subcutaneous tissues of the abdomen into the stomach, and inserting
the PEG or PEJ catheter through the puncture.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Nutrition
• The surgical opening is sutured tightly around the tube or catheter to
prevent leakage. Care of this opening before it heals requires surgical
asepsis.
• The catheter has an external bumper and an internal inflatable retention
balloon to maintain placement.
• When the tract is established (about 1 month), the tube or catheter can be
removed and reinserted for each feeding. Alternatively, a skin-level tube
can be used that remains in place
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Testing feeding tube placement
•Before feedings are introduced, tube placement
is confirmed by radiography, particularly when a
small-bore tube has been inserted or when the
client is at risk for aspiration.
•After placement is confirmed, nurse marks the
tube with indelible ink or tape at its exit point
from the nose and documents the length of
visible tubing for baseline data.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Testing
tube
placement
•The nurse isfeeding
responsible for
verifying
tube
placement (i.e., GI placement vs. respiratory
placement) before each intermittent feeding and at
regular intervals (e.g., at least once per shift) when
continuous feedings are being administered
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Testing feeding tube placement
•To check tube placement, radiographic verification of
tube placement is done (definitive method); however
repeated x-ray studies are not feasible in terms of
cost and exposure of client to radiation.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Testing feeding tube placement
• Methods nurses use to check tube placement include the following:
1. Injecting air
2. Aspirate GI secretions
3. Measure pH of aspirated fluid
4. Test aspirate for bilirubin. Bilirubin levels in lungs should be almost zero, while levels in the
stomach will be approximately 1.5 mg/dL and in intestine more than 10 mg/dL
5. Confirm length of tube insertion
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Testing feeding tube placement
1. Inject Air
Inject 10-30 mL of air into tube while listening with stethoscope for whooshing sound over epigastrium (below sternum and above
umbilicus)
2. Aspirate GI secretions
Because small-bore tubes offer more resistance during aspirations than large-bore tubes and are more likely to collapse
when negative pressure is applied, it may not be possible to obtain an aspirate. If obtained, gastric secretions tend to be a
grassy-green, off-white, or tan color; intestinal fluid is stained with bile and has a golden yellow or brownish green color.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Testing feeding tube placement
3. Measure pH of aspirated fluid
Testing the pH of aspirate can help distinguish gastric from respiratory and
intestinal placement as follows:
• Gastric aspirates tend to be acidic and have a pH of 1 to 4 but may be as
high as 6 if the client is receiving medications that control gastric acid.
• Small intestine aspirates generally have a pH equal to or higher than 6.
• Respiratory secretions are more alkaline with values of 7 or higher.
However, there is a slight possibility of respiratory placement when the pH
reading is as low as 5.
• Therefore, when pH readings are 5 or higher, radiographic confirmation of
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
tube location needs to be considered, especially in clients with diminished
Testing feeding tube placement
4. Confirm length of tube insertion
•Confirm length of tube insertion with the insertion mark.
If more of the tube is now exposed, the position of the
tip should be questioned.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Testing feeding tube placement
More research is required to devise effective alternatives to radiographic
verification of tube placement, especially for placement of small-bore tubes. In the
meantime, nurses should:
(a)ensure initial radiographic verification of small-bore tubes
(b)aspirate contents when possible and check their acidity
(c)closely observe the client for signs of obvious distress
(d) consider tube dislodgment after episodes of coughing, sneezing, and vomiting.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral feedings
Purpose:
1. To restore or maintain nutritional status
2. To administer medications
Assessment:
1. For any clinical signs of malnutrition or dehydration
2. For allergies to any food in the feeding
3. For presence of bowel sounds
4. For any signs of lack of tolerance to previous feedings
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Enteral Feedings
• Type and frequency of feedings and
amounts to be administered are
ordered by physician.
• Liquid feeding mixtures are available
commercially or may be prepared by
the dietary department in accordance
with the physician’s orders
• A standard formula provides 1 Kcal
per milliliter of solution with protein,
fat, carbohydrate, minerals, and
vitamins in specified proportions.
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Enteral Feeding
•Enteral feedings can be given:
-intermittently
or
-continuously
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Feeding
•Enteral feedings can be given:
-intermittently (administration 300-500 mL of enteral
formula several times per day, over at least 30 minutes,
into stomach; bolus intermittent feedings are not
recommended as it is rapid), or
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Enteral Feeding
Enteral feedings can be
given:
-continuously
(administered over 24-
hour period using infusion
pump (kangaroo pump)
that guarantees constant
flow rate; no more than 60
mL/hr)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Assess
feeding contents
Enteralresidual
Feeding
1. If the tube is placed in the stomach, aspirate all contents
and measure the amount before administering the feeding
Rationale: to evaluate absorption of the last feeding;
whether undigested formula from a previous feeding
remains. If tube is in small intestine, residual contents
cannot be aspirated.
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Assess residual feeding contents
Enteral Feeding
2. If 100 mL (or more than half of the last feeding) is withdrawn, check
with the nurse in charge or refer to agency policy before you proceed. The
precise amount is usually determined by the primary care provider’s order
or by agency
Rationale: At some agencies, a feeding is delayed when the specified
amount
Or
3. Reinstill the gastric contents into the stomach if this is the agency policy
or primary care provider’s order
Rationale: Removal of the contents could disturb the client’s electrolyte
balance.
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Enteral Feeding
Assess residual feeding contents
4. If the client is on continuous feeding, check the gastric residual every 4 to 6 hours or
according to agency protocol
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Enteral
Feeding
• Enteral feedings administered through:
-open systems (use open-top container or syringe for administration; enteral
feedings used with open systems are provided in flip-top cans or powdered
formulas that are constituted with sterile water. Open systems should have
no more than 8-12 hours of formula poured at one time; at the end of these
hours, remaining formula should be discarded and container rinsed before
new formula is poured); bag and tubing should be replaced q 24 hours)
-closed systems (prefilled container attached to enteral access device, can
hang safely for 48 hours)
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
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Closed system
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Enteral Feedings
•Before administering a tube feeding, nurse must
determine any food allergies of client and assess
tolerance to previous feedings
•Also nurse must assess expiration date on
commercially prepared formula or preparation date
and time of agency-prepared solution and discard
any formula that has expired or that was prepared
more than 24 hours previously
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Enteral Feedings
• Feedings are usually administered at room temperature unless the order specifies otherwise
• The nurse warms the specified amount of solution in warm water or leaves it to stand for a
while until it reaches room temperature
• Continuous-feeding formulas should be kept cold; however, excessively cold formulas can
reduce flow of digestive enzymes by causing vasoconstriction and may cause cramps
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Managing clogged feeding tubes
• To prevent clogged feeding tubes, flush liberally (at least 30 mL water) before, between, and after
each separate medication is instilled, using 60-mL piston syringe
• Don not add medication to formula as combination could create precipitate that clogs the tube
• If all efforts to unclog tube fail, tube need to be removed
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Removing a Nasogastric Tube
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Removing a Nasogastric Tube
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Removing a Nasogastric Tube
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Sample documentation
11/4/2019 1030 #8 Fr feeding tube inserted without difficulty through R nare. Ascertained
proper placement using auscultation of injected air and aspiration of 20 mL gastric content,
green in color, c pH=4. Tube secured to nose. ------------------------------------------------------R.
Fakhry, RN
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Evaluation
• The goals established in the planning phase are evaluated according to specific desired
outcomes
• If the outcomes are not achieved, the nurse should explore the reasons
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
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